asthma

Management of Severe Refractory Asthma

Hope Smashey — Thu, 02 Oct 2025 16:58:22 +0000

Date Added:

October 2, 2025

Journal/Publication:

JAMA

Publication Date:

October 1, 2025

URL:

Management of Severe Refractory Asthma

Type:

Meta-analyses, Reviews, and Guidelines

Format:

Article

DOI (1):

10.1001/jama.2025.14449

Keywords

asthma

medications

environmental triggers

PMID (1):

41032334

MeSH

asthma

Specialization

A review of the evaluation and treatments for patients with severe refractory asthma. James W. Mold, MD, MPH

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This JAMA Insights explores the management of severe refractory asthma, including medications, access to specialists, and managing environmental triggers.

Author/s:

Juan Carlos Cardet, Sergio E. Chiarella, Michelle L. Hernandez

Postinfectious cough in adults

Erin Blanchette — Mon, 26 Feb 2024 16:23:27 +0000

Date Added:

February 26, 2024

Journal/Publication:

Canadian Medical Association Journal

Publisher:

Canadian Medical Association

Publication Date:

February 11, 2024

Issue:

Volume:

196

Pages:

E157

URL:

Postinfectious cough in adults

Type:

Meta-analyses, Reviews, and Guidelines

Format:

Article

DOI (1):

10.1503/cmaj.231523

Keywords

PMID (1):

38346782

MeSH

cough

bronchodilator agents

mucus

follow-up studies

asthma

A concise summary of what is known about the diagnosis and management of post infection cough. James W. Mold, MD, MPH

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Postinfectious cough affects 11%–25% of adults after a respiratory infection

Postinfectious cough is defined as a subacute cough, with symptoms lasting between 3 and 8 weeks.1 The preceding infection triggers an inflammatory cascade, increasing bronchial sensitivity and mucus production, while reducing mucus clearance.1

Author/s:

Kevin Liang, Philip Hui, Samantha Green

2020 Focused Updates to the Asthma Management Guidelines: At-a-Glance Guide

Aubrey Delammermore — Wed, 12 Apr 2023 05:00:00 +0000

Date Added:

April 12, 2023

Journal/Publication:

NIH Publication No. 20-HL-8142

Publisher:

US Department of Health and Human Services

Publication Date:

December 1, 2020

URL:

2020 Focused Updates to the Asthma Management Guidelines: At-a-Glance Guide

Type:

Meta-analyses, Reviews, and Guidelines

Format:

Article

Keywords

MeSH

Patient Care Management

asthma

Judgment

Anti-Asthmatic Agents

A concise summary of the 2020 NIH Guidelines for management of asthma. James W. Mold, MD, MPH

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This At-A-Glance Guide describes a treatment management approach based on recommendations from the 2020 Focused Updates to the Asthma Management Guidelines: A Report from the National Asthma Education and Prevention Program Coordinating Committee Expert Panel Working Group. Step diagrams from the 2007 Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma (EPR-3) were updated with the new recommendations. The diagrams are intended to help clinicians integrate the new recommendations into clinical care, and are meant to assist, and not replace, clinical judgment or decision-making for individual patient
management, with input from individuals with asthma about their preferences

Air Quality Index and Childhood Asthma: A Pilot Randomized Clinical Trial Intervention

Aubrey Delammermore — Wed, 18 Jan 2023 06:00:00 +0000

Date Added:

January 18, 2023

Journal/Publication:

American Journal of Preventative Medicine

Publisher:

Elsevier

Publication Date:

January 13, 2023

Pages:

1-5

URL:

Air Quality Index and Childhood Asthma: A Pilot Randomized Clinical Trial Intervention

Type:

Clinical Research Results

Format:

Article

DOI (1):

10.1016/j.amepre.2022.12.010

Keywords

PMID (1):

36642643

MeSH

air pollution

Surveys and Questionnaires

child

random allocation

asthma

Adding instructions regarding use of the Air Quality Index to asthma action plans improved asthma control in children. James W. Mold, MD, MPH

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Introduction: To reduce air pollution exposure, the U.S. asthma guidelines recommend that children check the Air Quality Index before outdoor activity. Whether adding the Air Quality Index and recommendations to asthma action plans reduces exacerbations and improves control and quality of life in children with asthma is unknown.

Methods: A pilot, unblinded, randomized clinical trial of 40 children with persistent asthma, stratified by age and randomized 1:1, recruited from the University of Pittsburgh Medical Center Children's Hospital of Pittsburgh (Pittsburgh, PA) was conducted. All participants received asthma action plans and Air Quality Index education. The intervention group received printed Air Quality Index information and showed the ability to use AirNow. Asthma exacerbations were assessed through a questionnaire, asthma control was assessed with the Asthma Control Test and Childhood Asthma Control Test, and quality of life was assessed with the Pediatric Asthma Quality of Life Questionnaire. After randomization (July-October 2020), participants were followed monthly for 6 months (exit January-March 2021). Outcome differences between groups were evaluated at the exit visit and over time (analysis was in 2021).

Results: At randomization, there were no significant differences in age, sex, race, or asthma severity. At exit, more intervention participants checked the Air Quality Index (63% vs 15%) with no differences in the proportion of asthma exacerbations or mean Childhood Asthma Control Test or Pediatric Asthma Quality of Life Questionnaire scores. The mean change in Asthma Control Test score was higher in the intervention group (change in Asthma Control Test=2.00 vs 0.15 for the control), which was modified by time (β=1.85, CI=0.09, 3.61). Physical activity was decreased overall and showed modification by treatment and time.

Conclusions: Addition of the Air Quality Index to asthma action plans led to improved asthma control by Asthma Control Test scores but may decrease outdoor activity.

Author/s:

Rosser, F. J., Rothenberger, S. D., Han, Y., Forno, E., Celedón, J. C.

Therapy for Mild to Moderate Asthma

Aubrey Delammermore — Wed, 27 Jul 2022 05:00:00 +0000

Date Added:

July 27, 2022

Journal/Publication:

JAMA

Publisher:

American Medical Association

Publication Date:

July 21, 2022

Pages:

URL:

Therapy for Mild to Moderate Asthma

Type:

Meta-analyses, Reviews, and Guidelines

Format:

Article

DOI (1):

10.1001/jama.2022.12258

Keywords

asthma

Mild to Moderate Asthma

therapy

recommendations

Asthma Therapy

PMID (1):

35862052

MeSH

asthma

adrenal cortex hormones

nebulizers and vaporizers

formoterol fumarate

-(2-(4-azidobenzamidino)ethyl)-5-hydroxyindole

Updated guidelines for management of mild to moderate asthma. James W. Mold, MD,MPH

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GUIDELINE TITLE Global Strategy for Asthma Management
and Prevention (GINA Strategy Report)
RELEASE DATE April 26, 2021
PRIOR VERSION April 3, 2020
DEVELOPER AND FUNDING SOURCE The Global Initiative for
Asthma (GINA)
TARGET POPULATION Patients aged 12 y with asthma
MAJOR RECOMMENDATIONS
• Short-acting β-agonist (SABA) monotherapy is no longer
recommended (level of evidence: A).
• There is no distinction between mild-intermittent
and mild-persistent asthma; inhaled corticosteroid
(ICS)–containing therapies are recommended for
both. ICS-formoterol is recommended as the preferred
reliever inhaler (level of evidence: A).
• For treatment of moderate asthma, GINA recommends
ICS-formoterol maintenance and reliever therapy in
the preferred track (level of evidence: A).

Author/s:

Gray, S. E., Cife, A. S., Press, V. G.

Evaluation of Budesonide-Formoterol for Maintenance and Reliever Therapy Among Patients With Poorly Controlled Asthma A Systematic Review and Meta-analysis

Saige Blanchard — Thu, 10 Mar 2022 06:00:00 +0000

Date Added:

March 10, 2022

Journal/Publication:

JAMA Network Open

Publisher:

JAMA Network Open

Publication Date:

December 21, 2021

Issue:

Volume:

URL:

Evaluation of Budesonide-Formoterol for Maintenance and Reliever Therapy Among Patients With Poorly Controlled Asthma A Systematic Review and Meta-analysis

Type:

Meta-analyses, Reviews, and Guidelines

Format:

Article

DOI (1):

10.1001/jamanetworkopen.2022.0615

Keywords

Budesonide-Formoterol

therapy

asthma

Inhaler

PMID (1):

35230437

MeSH

For adults with moderate to severe asthma, use of a budesonide-formoterol inhaler for both maintenance and rescue (SMART protocol) appears to be more effective than usual step care with two or three different inhalers. (Once again, simpler is often better.) James W. Mold, MD, MPH

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Importance: The Global Initiative for Asthma (GINA) recommends 2 alternative treatments for patients receiving treatment at steps 3 to 5: single inhaler combination inhaled corticosteroid-formoterol as both maintenance and reliever (SMART) or inhaled corticosteroid-long-acting β2-agonist as maintenance plus short-acting β2-agonist as reliever.

Objective: To assess whether switching to SMART is associated with longer time to first severe asthma exacerbation compared with a step up or continuation of GINA treatment step with maintenance inhaled corticosteroid-long-acting β2-agonist plus short-acting β2-agonist reliever among patients with poorly controlled asthma.

Data sources: For this systematic review and meta-analysis, the literature, internal study databases at AstraZeneca and the Medical Research Institute of New Zealand, and references from a previous systematic review and meta-analysis on SMART were searched to identify randomized clinical trials published from January 1990 to February 2018, that compared budesonide-formoterol by SMART with maintenance inhaled corticosteroid-long-acting β2-agonist plus short-acting β2-agonist reliever.

Study selection: Trials of at least 24 weeks' duration were included if they reported baseline data on GINA treatment step, asthma control status, and efficacy measures of severe exacerbations. Included patients were adults and adolescents with asthma and baseline Asthma Control Questionnaire 5-item version scores of 1.5 or higher.

Data extraction and synthesis: Patient-level data were identified by independent extraction, and analyses were performed using a fixed-effect model. Data analysis was performed from August 2018 to November 2021.

Main outcomes and measures: The primary outcome was time to first severe asthma exacerbation associated with each treatment, analyzed by Cox proportional hazards regression.

Results: Overall, 4863 patients were included (3034 [62.4%] female; mean [SD] age, 39.8 [16.3] years). Switching patients with uncontrolled asthma at GINA step 3 (n = 1950) to SMART at either step 3 or 4 was associated with a prolonged time to first severe asthma exacerbation, with a 29% reduced risk compared with stepping up to step 4 inhaled corticosteroid-long-acting β2-agonist maintenance plus short-acting β2-agonist reliever (hazard ratio, 0.71; 95% CI, 0.52-0.97). For patients with uncontrolled asthma at step 3 and step 4 (n = 2913), switching to SMART was associated with a prolonged time to first severe asthma exacerbation and a 30% reduced risk compared with remaining at the same treatment step (hazard ratio, 0.70; 95% CI, 0.58-0.85).

Conclusions and relevance: In this systematic review and meta-analysis, for patients with poorly controlled asthma, SMART was associated with longer time to first severe asthma exacerbation compared with a step up or continuation of GINA step with maintenance inhaled corticosteroid-long-acting β2-agonist plus short-acting β2-agonist reliever. These findings suggest that if an adult or adolescent receiving treatment at GINA step 3 or 4 has poorly controlled asthma, it is preferable to switch to the SMART regimen rather than to step up or continue the GINA treatment step with maintenance inhaled corticosteroid-long-acting β2-agonist plus short-acting β2-agonist reliever therapy.

Author/s:

Beasley, R., Harrison, T., Peterson, S., Gustafson, P., Hamblin, A., Bengtsson, T., Fageras, M.

Triple vs Dual Inhaler Therapy and Asthma Outcomes in Moderate to Severe Asthma: A Systematic Review and Meta-analysis

Devin Evans — Fri, 21 May 2021 05:00:00 +0000

Date Added:

May 21, 2021

Journal/Publication:

Journal of the American Medical Association

Publication Date:

May 19, 2021

URL:

Triple vs Dual Inhaler Therapy and Asthma Outcomes in Moderate to Severe Asthma: A Systematic Review and Meta-analysis

Type:

Meta-analyses, Reviews, and Guidelines

Format:

Article

DOI (1):

10.1001/jama.2021.7872

Keywords

asthma

inhalers

Inhaler Therapy

PMID (1):

34009257

MeSH

Surveys and Questionnaires

An RCT comparing dual vs. triple medication inhaler therapy for chronic treatment of people with moderate to severe asthma. (a 5% reduction in severe exacerbations but no improvement in QOL) James W. Mold, MD. MPH

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Importance: The benefits and harms of adding long-acting muscarinic antagonists (LAMAs) to inhaled corticosteroids (ICS) and long-acting β2-agonists (LABAs) for moderate to severe asthma remain unclear.

Objective: To systematically synthesize the outcomes and adverse events associated with triple therapy (ICS, LABA, and LAMA) vs dual therapy (ICS plus LABA) in children and adults with persistent uncontrolled asthma.

Data sources: MEDLINE, Embase, CENTRAL, ICTRP, FDA, and EMA databases from November 2017, to December 8, 2020, without language restriction.

Study selection: Two investigators independently selected randomized clinical trials (RCTs) comparing triple vs dual therapy in patients with moderate to severe asthma.

Data extraction and synthesis: Two reviewers independently extracted data and assessed risk of bias. Random-effects meta-analyses, including individual patient-level exacerbation data, were used. The GRADE (Grading of Recommendations, Assessment, Development and Evaluation) approach was used to assess certainty (quality) of the evidence.

Main outcomes and measures: Severe exacerbations, asthma control (measured using the Asthma Control Questionnaire [ACQ-7], a 7-item list with each item ranging from 0 [totally controlled] to 6 [severely uncontrolled]; minimal important difference, 0.5), quality of life (measured using the Asthma-related Quality of Life [AQLQ] tool; score range, 1 [severely impaired] to 7 [no impairment]; minimal important difference, 0.5), mortality, and adverse events.

Results: Twenty RCTs using 3 LAMA types that enrolled 11 894 children and adults (mean age, 52 years [range, 9-71 years]; 57.7% female) were included. High-certainty evidence showed that triple therapy vs dual therapy was significantly associated with a reduction in severe exacerbation risk (9 trials [9932 patients]; 22.7% vs 27.4%; risk ratio, 0.83 [95% CI, 0.77 to 0.90]) and an improvement in asthma control (14 trials [11 230 patients]; standardized mean difference [SMD], -0.06 [95% CI, -0.10 to -0.02]; mean difference in ACQ-7 scale, -0.04 [95% CI, -0.07 to -0.01]). There were no significant differences in asthma-related quality of life (7 trials [5247 patients]; SMD, 0.05 [95% CI, -0.03 to 0.13]; mean difference in AQLQ score, 0.05 [95% CI, -0.03 to 0.13]; moderate-certainty evidence) or mortality (17 trials [11 595 patients]; 0.12% vs 0.12%; risk ratio, 0.96 [95% CI, 0.33 to 2.75]; high-certainty evidence) between dual and triple therapy. Triple therapy was significantly associated with increased dry mouth and dysphonia (10 trials [7395 patients]; 3.0% vs 1.8%; risk ratio, 1.65 [95% CI, 1.14 to 2.38]; high-certainty evidence), but treatment-related and serious adverse events were not significantly different between groups (moderate-certainty evidence).

Conclusions and relevance: Among children (aged 6 to 18 years) and adults with moderate to severe asthma, triple therapy, compared with dual therapy, was significantly associated with fewer severe asthma exacerbations and modest improvements in asthma control without significant differences in quality of life or mortality.

Author/s:

Kim, L.H.Y., Saleh, C., Whalen-Browne, A., O'Byrne, P.M., Chu, D.K.

Managing Asthma in Adolescents and Adults 2020 Asthma Guideline Update From the National Asthma Education and Prevention Program

Brian Desmarais — Mon, 14 Dec 2020 15:03:27 +0000

Date Added:

December 14, 2020

Journal/Publication:

JAMA Network

Publication Date:

December 3, 2020

Issue:

Volume:

323

URL:

Managing Asthma in Adolescents and Adults 2020 Asthma Guideline Update From the National Asthma Education and Prevention Program

Type:

Meta-analyses, Reviews, and Guidelines

Format:

Article

DOI (1):

doi:10.1001/jama.2020.21974

Keywords

asthma treatment

MeSH

treatment outcome

asthma

A summary of six significant changes and updates to the NHLBI Asthma Guidelines for adolescents and adults. James W. Mold, MD, MPH

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Importance Asthma is a major public health problem worldwide and is associated with excess morbidity, mortality, and economic costs associated with lost productivity. The National Asthma Education and Prevention Program has released the 2020 Asthma Guideline Update with updated evidence-based recommendations for treatment of patients with asthma.

Objective To report updated recommendations for 6 topics for clinical management of adolescents and adults with asthma: (1) intermittent inhaled corticosteroids (ICSs); (2) add-on long-acting muscarinic antagonists; (3) fractional exhaled nitric oxide; (4) indoor allergen mitigation; (5) immunotherapy; and (6) bronchial thermoplasty.

Evidence Review The National Heart, Lung, and Blood Advisory Council chose 6 topics to update the 2007 asthma guidelines based on results from a 2014 needs assessment. The Agency for Healthcare Research and Quality conducted systematic reviews of these 6 topics based on literature searches up to March-April 2017. Reviews were updated through October 2018 and used by an expert panel (n = 19) that included asthma content experts, primary care clinicians, dissemination and implementation experts, and health policy experts to develop 19 new recommendations using the GRADE method. The 17 recommendations for individuals aged 12 years or older are reported in this Special Communication.

Findings From 20 572 identified references, 475 were included in the 6 systematic reviews to form the evidence basis for these recommendations. Compared with the 2007 guideline, there was no recommended change in step 1 (intermittent asthma) therapy (as-needed short-acting β2-agonists [SABAs] for rescue therapy). In step 2 (mild persistent asthma), either daily low-dose ICS plus as-needed SABA therapy or as-needed concomitant ICS and SABA therapy are recommended. Formoterol in combination with an ICS in a single inhaler (single maintenance and reliever therapy) is recommended as the preferred therapy for moderate persistent asthma in step 3 (low-dose ICS-formoterol therapy) and step 4 (medium-dose ICS-formoterol therapy) for both daily and as-needed therapy. A short-term increase in the ICS dose alone for worsening of asthma symptoms is not recommended. Add-on long-acting muscarinic antagonists are recommended in individuals whose asthma is not controlled by ICS-formoterol therapy for step 5 (moderate-severe persistent asthma). Fractional exhaled nitric oxide testing is recommended to assist in diagnosis and monitoring of symptoms, but not alone to diagnose or monitor asthma. Allergen mitigation is recommended only in individuals with exposure and relevant sensitivity or symptoms. When used, allergen mitigation should be allergen specific and include multiple allergen-specific mitigation strategies. Subcutaneous immunotherapy is recommended as an adjunct to standard pharmacotherapy for individuals with symptoms and sensitization to specific allergens. Sublingual immunotherapy is not recommended specifically for asthma. Bronchial thermoplasty is not recommended as part of standard care; if used, it should be part of an ongoing research effort.

Conclusions and Relevance Asthma is a common disease with substantial human and economic costs globally. Although there is no cure or established means of prevention, effective treatment is available. Use of the recommendations in the 2020 Asthma Guideline Update should improve the health of individuals with asthma.

Author/s:

Cloutier, M.M., Dixon, A.E., Krishnan, J.A.

Global Initiative for Asthma report: How will new recommendations affect practice in Canada?

Brian Desmarais — Tue, 28 Apr 2020 16:16:14 +0000

Date Added:

April 28, 2020

Journal/Publication:

Canadian Medical Association Journal

Publisher:

Canadian Medical Association

Publication Date:

April 1, 2020

Issue:

Volume:

193

Pages:

E456- E458

URL:

Global Initiative for Asthma report: How will new recommendations affect practice in Canada?

Type:

Meta-analyses, Reviews, and Guidelines

Format:

Article

DOI (1):

10.1503/cmaj.191445

Keywords

asthma

asthma treatment

recommendations

The Global Initiative

MeSH

asthma

adrenal cortex hormones

formoterol fumarate

The Global Initiative on Asthma has updated its recommendations for management of mild intermittent asthma. James W. Mold, MD, MPH

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Not available.

Author/s:

Beauchesne, M., Lemiere, C.

Managing Asthma during COVID-19: An Example for Other Chronic Conditions in Children and Adolescents

Brian Desmarais — Wed, 22 Apr 2020 23:55:59 +0000

Date Added:

April 22, 2020

Journal/Publication:

The Journal of Pediatrics

Publication Date:

April 17, 2020

URL:

Managing Asthma during COVID-19: An Example for Other Chronic Conditions in Children and Adolescents

Type:

Meta-analyses, Reviews, and Guidelines

Format:

Article

DOI (1):

https://doi.org/10.1016/j.jpeds.2020.04.049

Keywords

treatment

asthma

2019 novel coronavirus

MeSH

This might be useful information for those taking care of a number of children with asthma. James W. Mold, MD, MPH

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Not available.

Author/s:

Abrams, E.M.

Association of use of cleaning products with respiratory health in a Canadian birth cohort

Brian Desmarais — Tue, 18 Feb 2020 16:35:59 +0000

Date Added:

February 18, 2020

Journal/Publication:

Canadian Medical Association Journal

Publication Date:

February 18, 2020

Issue:

Volume:

192

Pages:

E154-E161

URL:

Association of use of cleaning products with respiratory health in a Canadian birth cohort

Type:

Clinical Research Results

Format:

Article

DOI (1):

https://doi.org/10.1503/cmaj.190819

Keywords

MeSH

Perhaps it is a combination of excessive cleanliness and exposure to the cleaning products that increase the risk of asthma in children. James W. Mold, MD, MPH

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Abstract

BACKGROUND: Comprehensive longitudinal studies are important for understanding the complex risk factors, pathways, exposures and interactions that lead to the development and persistence of asthma. We aimed to examine associations between use of household cleaning products in early life and childhood respiratory and allergic disease using data from the Canadian Healthy Infant Longitudinal Development (CHILD) Cohort Study.

METHODS: We summed responses from parental questionnaires that indicated the frequency of use of 26 household cleaning products in the homes of 2022 children from this birth cohort when they were 3–4 months of age to create a cumulative Frequency of Use Score (FUS). We used multivariable logistic regression models to assess whether frequent compared with less frequent use was associated with recurrent wheeze, atopy or asthma diagnosis, as defined by the questionnaire and clinical assessments at age 3 years. Data were collected between 2008 and 2015.

RESULTS: Children in homes with a higher frequency of use of cleaning products in infancy, as determined by an interquartile range increase, had higher odds of recurrent wheeze (adjusted odds ratio [OR] 1.35, 95% confidence interval [CI] 1.11–1.64), recurrent wheeze with atopy (adjusted OR 1.49, 95% CI 1.02–2.16) and asthma diagnosis (adjusted OR 1.37, 95% CI 1.09–1.70), but no increase in the odds of atopy at age 3 years (adjusted OR 1.14, 95% CI 0.96–1.35). Compared with the lowest tertile of FUS exposure, infants in the highest tertile had higher odds of acquiring asthma. Stratification of the results showed that females had higher ORs than males for all outcomes, although the p values for this sex difference did not reach statistical significance.

INTERPRETATION: Frequent use of household cleaning products in early life was associated with an increased risk for childhood wheeze and asthma but not atopy at age 3 years. Our findings add to the understanding of how early life exposures to cleaning products may be associated with the development of allergic airway disease and help to identify household behaviours as a potential area for intervention.

Author/s:

McCandless, L., Parks, J., Dharma, C., Brook, J., Turvey, S.E., Mandhane, P., Becker, A.B., Kozyrskyj, A.L., Azad, M.B., Moraes, T.J., Lefebvre, D.L., Sears, M.R., Subbarao, P., Scott, J., Takaro, T.K.

Association of E-Cigarette Use With Respiratory Disease Among Adults: A Longitudinal Analysis

John Bayhi — Thu, 02 Jan 2020 20:08:03 +0000

Date Added:

January 2, 2020

Journal/Publication:

American Journal of Preventive Medicine

Publisher:

Elsevier Inc.

Publication Date:

December 11, 2019

URL:

Association of E-Cigarette Use With Respiratory Disease Among Adults: A Longitudinal Analysis

Type:

Clinical Research Results

Format:

Article

DOI (1):

10.1016/j.amepre.2019.07.028

Keywords

e-cigarette or vaping product use-associated lung injury

PMID (1):

31859175

MeSH

Adult

electronic nicotine delivery systems

This longitudinal study documents an increase in respiratory problems associated with e-cigarette use and supports a mechanism distinct from those associated with respiratory problems associated with standard cigarettes. The combination of e-cigarettes and standard cigarettes appears to be particularly hazardous. James W. Mold, MD, MPH.

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INTRODUCTION:

E-cigarettes deliver an aerosol of nicotine by heating a liquid and are promoted as an alternative to combustible tobacco. This study determines the longitudinal associations between e-cigarette use and respiratory disease controlling for combustible tobacco use.

METHODS:

This was a longitudinal analysis of the adult Population Assessment of Tobacco and Health Waves 1, 2, and 3. Multivariable logistic regression was performed to determine the associations between e-cigarette use and respiratory disease, controlling for combustible tobacco smoking, demographic, and clinical variables. Data were collected in 2013-2016 and analyzed in 2018-2019.

RESULTS:

Among people who did not report respiratory disease (chronic obstructive pulmonary disease, chronic bronchitis, emphysema, or asthma) at Wave 1, the longitudinal analysis revealed statistically significant associations between former e-cigarette use (AOR=1.31, 95% CI=1.07, 1.60) and current e-cigarette use (AOR=1.29, 95% CI=1.03, 1.61) at Wave 1 and having incident respiratory disease at Waves 2 or 3, controlling for combustible tobacco smoking, demographic, and clinical variables. Current combustible tobacco smoking (AOR=2.56, 95% CI=1.92, 3.41) was also significantly associated with having respiratory disease at Waves 2 or 3. Odds of developing respiratory disease for a current dual user (e-cigarette and all combustible tobacco) were 3.30 compared with a never smoker who never used e-cigarettes. Analysis controlling for cigarette smoking alone yielded similar results.

CONCLUSIONS:

Use of e-cigarettes is an independent risk factor for respiratory disease in addition to combustible tobacco smoking. Dual use, the most common use pattern, is riskier than using either product alone.

Author/s:

Bhatta, DN, Glantz, SA

Step-Up Therapy in Black Children and Adults with Poorly Controlled Asthma

John Bayhi — Thu, 26 Sep 2019 14:21:17 +0000

Date Added:

September 26, 2019

Journal/Publication:

The New England Journal of Medicine

Publisher:

Massachusetts Medical Society

Publication Date:

September 26, 2019

Issue:

Volume:

381

Pages:

1227-1239

URL:

Step-Up Therapy in Black Children and Adults with Poorly Controlled Asthma

Type:

Clinical Research Results

Format:

Article

DOI (1):

10.1056/NEJMoa1905560

Keywords

asthma

African Americans

glucocorticoids

randomized control trial

PMID (1):

31553835

MeSH

fluticasone-salmeterol drug combination

Some patients with poorly controlled asthma need significantly increased doses of inhaled corticosteroids. James W. Mold, MD, MPH

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BACKGROUND:

Morbidity from asthma is disproportionately higher among black patients than among white patients, and black patients constitute the minority of participants in trials informing treatment. Data indicate that patients with inadequately controlled asthma benefit more from addition of a long-acting beta-agonist (LABA) than from increased glucocorticoids; however, these data may not be informative for treatment in black patients.

METHODS:

We conducted two prospective, randomized, double-blind trials: one involving children and the other involving adolescents and adults. In both trials, the patients had at least one grandparent who identified as black and had asthma that was inadequately controlled with low-dose inhaled glucocorticoids. We compared combinations of therapy, which included the addition of a LABA (salmeterol) to an inhaled glucocorticoid (fluticasone propionate), a step-up to double to quintuple the dose of fluticasone, or both. The treatments were compared with the use of a composite measure that evaluated asthma exacerbations, asthma-control days, and lung function; data were stratified according to genotypic African ancestry.

RESULTS:

When quintupling the dose of fluticasone (to 250 μg twice a day) was compared with adding salmeterol (50 μg twice a day) and doubling the fluticasone (to 100 μg twice a day), a superior response occurred in 46% of the children with quintupling the fluticasone and in 46% of the children with doubling the fluticasone and adding salmeterol (P = 0.99). In contrast, more adolescents and adults had a superior response to added salmeterol than to an increase in fluticasone (salmeterol-low-dose fluticasone vs. medium-dose fluticasone, 49% vs. 28% [P = 0.003]; salmeterol-medium-dose fluticasone vs. high-dose fluticasone, 49% vs. 31% [P = 0.02]). Neither the degree of African ancestry nor baseline biomarkers predicted a superior response to specific treatments. The increased dose of inhaled glucocorticoids was associated with a decrease in the ratio of urinary cortisol to creatinine in children younger than 8 years of age.

CONCLUSIONS:

In contrast to black adolescents and adults, almost half the black children with poorly controlled asthma had a superior response to an increase in the dose of an inhaled glucocorticoid and almost half had a superior response to the addition of a LABA. (Funded by the National Heart, Lung, and Blood Institute; BARD ClinicalTrials.gov number, NCT01967173.).

Author/s:

Wechsler, ME, Szefler, SJ, Ortega, VE, Pongracic, JA, Chinchili, V, Lima, JJ, Krishnan, JA, Kunselman, SJ, Mauger, D, Bleecker, ER, Bacharier, LB, Beigelman, A, Benson, M, Blake, KV, Cabana, MD, Cardet, JC, Castro, M, Chmiel, JF, Covar, R, Denlinger, L, DiMango, E, Fitzpatrick, AM, Gentile, D, Grossman, N, Holguin, F, Jackson, DJ, Kumar, H, Kraft, M, LaForce, CF, Lang, J, Lazarus, SC, Lemanske, RF Jr, Long, D, Lugogo, N, Martinez, F, Meyers, DA, Moore, WC, Moy, J, Naureckas, E, Olin, JT, Peters, SP, Phipatanakul, W, Que, L, Raissy, H, Robison, RG, Ross, K, Sheehan, W, Smith, LJ, Solway, J, Sorkness, CA, Sullivan-Vedder, L, Wenzel, S, Israel, E, NHLBI AsthmaNet

Controlled Trial of Budesonide–Formoterol as Needed for Mild Asthma

Tracy Ashby — Thu, 23 May 2019 05:00:00 +0000

Date Added:

May 23, 2019

Journal/Publication:

The New England Journal of Medicine

Publisher:

Massachusetts Medical Society

Publication Date:

May 23, 2019

Issue:

Volume:

380

Pages:

2020-2030

URL:

Controlled Trial of Budesonide-Formoterol as Needed for Mild Asthma.

Type:

Clinical Research Results

Format:

Article

DOI (1):

10.1056/NEJMoa1901963

Keywords

asthma

randomized control trial

PMID (1):

31112386

MeSH

nebulizers and vaporizers

metered dose inhalers

In this randomized clinical trial, budesonide–formoterol (e.g. Symbacort) used on an as-needed basis resulted in a lower risk of severe exacerbation of asthma than as-needed use of a short-acting SABA; the risk was similar to that of budesonide maintenance therapy plus as-needed SABA. James W. Mold, MD, MPH

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BACKGROUND:

In double-blind, placebo-controlled trials, budesonide-formoterol used on an as-needed basis resulted in a lower risk of severe exacerbation of asthma than as-needed use of a short-acting β2-agonist (SABA); the risk was similar to that of budesonide maintenance therapy plus as-needed SABA. The availability of data from clinical trials designed to better reflect clinical practice would be beneficial.

METHODS:

We conducted a 52-week, randomized, open-label, parallel-group, controlled trial involving adults with mild asthma. Patients were randomly assigned to one of three treatment groups: albuterol (100 μg, two inhalations from a pressurized metered-dose inhaler as needed for asthma symptoms) (albuterol group); budesonide (200 μg, one inhalation through a Turbuhaler twice daily) plus as-needed albuterol (budesonide maintenance group); or budesonide-formoterol (200 μg of budesonide and 6 μg of formoterol, one inhalation through a Turbuhaler as needed) (budesonide-formoterol group). Electronic monitoring of inhalers was used to measure medication use. The primary outcome was the annualized rate of asthma exacerbations.

RESULTS:

The analysis included 668 of 675 patients who underwent randomization. The annualized exacerbation rate in the budesonide-formoterol group was lower than that in the albuterol group (absolute rate, 0.195 vs. 0.400; relative rate, 0.49; 95% confidence interval [CI], 0.33 to 0.72; P<0.001) and did not differ significantly from the rate in the budesonide maintenance group (absolute rate, 0.195 in the budesonide-formoterol group vs. 0.175 in the budesonide maintenance group; relative rate, 1.12; 95% CI, 0.70 to 1.79; P = 0.65). The number of severe exacerbations was lower in the budesonide-formoterol group than in both the albuterol group (9 vs. 23; relative risk, 0.40; 95% CI, 0.18 to 0.86) and the budesonide maintenance group (9 vs. 21; relative risk, 0.44; 95% CI, 0.20 to 0.96). The mean (±SD) dose of inhaled budesonide was 107±109 μg per day in the budesonide-formoterol group and 222±113 μg per day in the budesonide maintenance group. The incidence and type of adverse events reported were consistent with those in previous trials and with reports in clinical use.

CONCLUSIONS:

In an open-label trial involving adults with mild asthma, budesonide-formoterol used as needed was superior to albuterol used as needed for the prevention of asthma exacerbations. (Funded by AstraZeneca and the Health Research Council of New Zealand; Novel START Australian New Zealand Clinical Trials Registry number, ACTRN12615000999538.).

Author/s:

Beasley, Richard, Holliday, Mark, Reddel, Helen K., Braithwaite, Irene, Ebmeier, Stefan, Hancox, Robert J., Harrison, Tim, Houghton, Claire, Oldfield, Karen, Papi, Alberto, Pavord, Ian D., Williams, Mathew, Weatherall, Mark

Inhaler Technique Education and Exacerbation Risk in Older Adults with Asthma or Chronic Obstructive Pulmonary Disease: A Meta-Analysis

Tracy Ashby — Tue, 30 Oct 2018 05:00:00 +0000

Date Added:

October 30, 2018

Journal/Publication:

Journal of the American Geriatrics Society

Publisher:

John Wiley & Sons, Inc.

Publication Date:

October 6, 2018

URL:

Inhaler Technique Education and Exacerbation Risk in Older Adults with Asthma or Chronic Obstructive Pulmonary Disease: A Meta‐Analysis

Type:

Meta-analyses, Reviews, and Guidelines

Format:

Article

DOI (1):

10.1111/jgs.15602

Keywords

chronic obstructive pulmonary disease

MeSH

pulmonary disease, chronic obstructive

nebulizers and vaporizers

asthma

This meta-analysis, focused on COPD patients, is a reminder of the importance of training patients to use their inhalers properly. That suggests that practices have at least one inhaler trainer and placebo inhalers or that patients requiring inhalers should be referred to a respiratory therapist or pharmacist for training.

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Objectives

To evaluate the effect of inhaler education programs on clinical outcomes and exacerbation rates in older adults with asthma or chronic obstructive pulmonary disease (COPD).

Design

Systematic review and meta‐analysis.

Setting and Participants

Older adults with asthma or COPD, either in primary or secondary health care and pharmacy setting.

Measurements

We searched the Medline, Embase, and Central databases according to the main eligibility criteria for inclusion: systematic reviews, meta‐analysis, clinical trials and quasi‐experimental studies; participants aged 65 and older; education on inhaler technique and reporting of disease control and exacerbation rates. We used the Grading of Recommendations, Assessment, Development and Evaluations scale for quality assessment and used a random‐effect model with Mantel–Haenszel adjustment to perform a meta‐analysis.

Results

We included 8 studies (4 randomized, 4 quasi‐experimental) with a total of 1,812 participants. The most frequent type of intervention was physical demonstration of inhaler technique, training with placebo devices. Five studies showed significant reduction in exacerbation rates (pooled risk ratio=0.71, 95% confidence interval=0.59–0.86; p < .001), although effect on disease control and quality of life showed high discrepancy in the reported results, and all randomized studies revealed uncertainty in their risk of bias assessment.

Conclusion

All interventions seemed to improve inhaler performance and clinically relevant outcomes, but a placebo device could be the most effective. There is evidence that interventions reduce exacerbation risk in older adults, although to an overall moderate degree.

Author/s:

Maricoto, Tiago, Monteiro, Luís, Gama, Jorge M. R., Correia-de-Sousa, Jamie, Taborda-Barata, Luís